LA County reduces COVID-19 contact tracing

After Julianne Cline walked out and was tested for COVID-19 in June, text messages and voicemails quickly piled up from Los Angeles County contact tracers who wanted to speak to her.

Cline, 32, ignored them. She had been sick for days, and by the time she woke up from bed to get officially tested, it seemed like “by the time they did contact tracing, it would have been so long these people would probably have already got sick,” the Manhattan Beach resident said.

Additionally, she said, “I just didn’t feel comfortable sharing my personal experience with the county.”

As the pandemic drags on, LA County contact tracers have struggled to reach and interview people with COVID. In January, amid a crush of cases driven by the Omicron variant, there were weeks when contact tracers reached and interviewed fewer than 10% of cases attributed to them, according to county data.

This summer, that number has stalled below 30% in recent weeks — better than during the winter surge, but well below the success rates seen for LA County contact tracers earlier in the pandemic. And even when they persuaded people to be interviewed, few of those phone calls led to additional conversations with other people they might have exposed, according to county statistics.

Many other COVID cases are likely never traced to contact tracers, as many Angelenos rely on home tests that are never reported to the county.

Cline, for example, had already tested positive in a home test days before deciding to confirm her case with a PCR test. At the University of Washington, researchers have estimated that less than 14% of positive cases in the United States are detected and reported in official counts.

The end result is that only a fraction of COVID cases are followed up with phone calls to alert others and try to prevent more infections.

Experts say contact tracing, long seen as a tool to stop the spread of viruses, has become an increasingly Sisyphean task in the face of rampant COVID infections, increasingly contagious subvariants and an exhausted public. .

Contact tracing “isn’t quite having the impact it once had,” said Adriane Casalotti, head of government and public affairs at the National Assn. county and city health officials. “With the communities largely reopened, it is very difficult to say how many contacts you have had, and even if you can say that, you can have 20, 30 or 40 contacts. … The logistics of contacting these people are very difficult. There is not enough time in the day.

The newer variants appear to have had a shorter time to onset of symptoms and spread more easily.

“It really cuts down on the time you have to reach someone,” said Richard S. Garfein, a professor at UC San Diego’s Herbert Wertheim School of Public Health and Human Longevity Science. “Getting cases willing to speak to a case investigator and identify their contacts – and then be able to turn around and notify those contacts within 24 to 48 hours – becomes really difficult.

In March 2020 the thought was “this is a brand new pandemic and we can hopefully stop it in its tracks, or mitigate the impact and buy people time so they don’t spread it more until we get a vaccine,” said associate professor Andrew Noymer. of Population Health and Disease Prevention at UC Irvine.

Now, “I just don’t see that we’re going to contact to get out of this,” Noymer said, especially as people continued to mingle but stopped wearing masks. He argued that time and money should instead be spent on other efforts, such as expanding PCR testing for coronavirus, or redeploying contact tracers to track down monkeypox.

Earlier this year, the Centers for Disease Control and Prevention stopped recommending universal contact tracing for COVID-19, instead urging health departments to focus those efforts on high-risk settings such as nursing homes. long term and prisons.

Many cities have halted or scaled back efforts: Washington, DC, laid off workers in June, officially ending its coronavirus contact tracing program, the Washington Post reported. New York City said it is ending its primary program this spring.

At one point, LA County had enlisted about 2,800 contact tracers to find people who tested positive and contact contacts they may have exposed. As of July, the county had about 100 employees dedicated to contact tracing for COVID-19 — a fraction of the workforce it once devoted to the effort.

The LA County Public Health Department said its “limited resources (are) focused on other strategies, including vaccines and treatments, that were not available earlier in the pandemic.” Its contact tracers are now prioritizing cases among the elderly and those in “high-risk” ZIP codes, a spokesperson said.

It also began sending online interview via cell phone and email to allow people “to complete the case interview at their own pace and at their own pace,” the department said.

A separate team is still dedicated to finding cases in nursing homes and correctional facilities. And as monkeypox has become a public health threat, LA County has also launched contact tracing for the disease: About 200 public health nurses who investigate the disease in LA County are carrying out now tracing contacts for monkeypox as part of their duties, according to the public health directorate.

Experts have said monkeypox may be better suited to contact tracing than COVID because it is harder to transmit, is in lower numbers and has a longer incubation period.

Alexander Morgan, who until recently worked as a contact tracer through an LA County contractor, was dismayed that the county had reduced the number of contact tracers for COVID as case numbers remain high .

“It makes no sense,” Morgan said. “You want experienced contact tracers during a power surge. It’s like a hospital that empties its staff.

Morgan said in the winter, as cases piled up, contact tracers made fewer attempts to reach people before dropping those cases. At one point in January, LA County contact tracers were only phoning about a quarter of the cases assigned to them that day, according to county data.

By July, contact tracers were again contacting the vast majority of cases assigned to them within a day, according to county figures. But the majority of these attempts did not end in a successful interview. Morgan said many people he called would say, “I don’t have time for this.”

Cline, the Manhattan Beach resident who ignored calls from contact tracers, said at some point she started getting text messages offering her gift cards if she called them back. This only made her more skeptical. “I was like, ‘Is this a scam?'” she said.

It wasn’t: The county’s public health department said it was in fact offering gift cards through its contact tracing program. Garfein said that more than two years into the pandemic, “unfortunately, I think the audience is exhausted – and I don’t know how to get it back.”

Even when contact tracers reach people who test positive for the coronavirus, the trail often goes cold after that.

In a recent week in July, LA County contact tracers were assigned nearly 24,000 cases; successfully interviewed less than 5,000 of these people; identified 466 contacts from their calls and ultimately interviewed only 62 of those contacts, according to county data.

Even if relatively few people are affected, contact tracing may have other benefits, health officials have pointed out. In addition to preventing the spread of cases, phone calls can connect people to county support and encourage vaccinations and boosters.

“Any contact tracing is good contact tracing — as long as resources aren’t taken from other more efficient things,” said Dr. John Swartzberg, clinical professor emeritus at the UC Berkeley School of Public Health. Right now, “there is so much COVID that contact tracing plays a minor role.”

But “contact tracing can be extremely helpful in keeping us at a very low level” when cases have dropped, Swartzberg said. And if public health departments drop such programs when cases are overwhelming, it can be difficult to reinstate them when contact tracing might be more effective, Swartzberg argued.

“Dismantling the infrastructure to effectively conduct contact tracing does not serve public health at all,” said Dr. George Rutherford, professor of epidemiology at UC San Francisco. Over the past few decades, “public health has been systematically dismantled and underfunded. We paid the price for it during COVID. We no longer want to pay the price. »

Rutherford added that although the incubation period for the latest variants is short, making it harder to reach people before infections spread, such calls can also alert people who may have been exposed to get tested. and process faster. If people in their 80s have been exposed, “you want to put them on Paxlovid if they’re positive,” Rutherford said.

“There are probably some situations where it’s highly justified — like a nursing home — and others like a rock concert or a walk through downtown Los Angeles where you can’t name it anyway. your contacts,” Rutherford said.

Dr. Christopher Longhurst, chief medical officer at UC San Diego Health, said another tool — anonymous notifications of COVID exposures via a smartphone app — can continue to help control infections by alerting strangers who spent time unmasked around someone who tested positive.

The CA Notify app, promoted by the California Department of Public Health, now has 7.5 million active users and notifies an average of five people each time someone reports they’ve tested positive, said Longhurst, who helped manage and evaluate the system.

The results are still being evaluated, but “we’re clearly helping to prevent hundreds of thousands of infections,” Longhurst said.

Cline said she did not activate any apps to alert people who may have been around her while she was infected.

“If I was asked to share all the places I’ve been and all the people I’ve seen, there would probably be hundreds that could have walked past me,” she said. “We’re no longer in a place where your only interaction a week may have been with just four people.”